Provider Demographics
NPI:1427669654
Name:DOHERTY, DONNA JEAN (AGNP-BC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 NEW HYDE PARK RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1206
Mailing Address - Country:US
Mailing Address - Phone:516-327-0001
Mailing Address - Fax:
Practice Address - Street 1:3003 NEW HYDE PARK RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1206
Practice Address - Country:US
Practice Address - Phone:516-327-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309821363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY309821OtherNYS LICENSE